A comparison between laparoscopy and hysteroscopy approaches in the treatment of symptomatic isthmocele: A systematic review and meta-analysis

Abstract

Objective

To compare the clinical outcomes of laparoscopy and hysteroscopy in the treatment of symptomatic isthmocele using a systematic review and meta-analysis.

Methods

A comprehensive search of PubMed, Scopus, and Web of Science was performed until November 11, 2024. Studies evaluating outcomes of laparoscopy or hysteroscopy intervention for treating symptomatic isthmocele were included in this study. A random-effects model was employed for heterogeneous data. The study is registered in PROSPERO with registration number CRD420251028603.

Results

Nine studies involving 797 patients were included. Hysteroscopy demonstrated significantly less intraoperative blood loss (SMD: −2.28, 95 % CI: −3.65 to −0.90) and shorter hospital stays (SMD: −2.62, 95 % CI: −3.52 to −1.72), but the operative time difference was non-significant. Both approaches were equally effective in symptom resolution and defect repair (OR: 0.80, 95 % CI: 0.21–2.97). However, laparoscopic repair was associated with better outcomes for dysmenorrhea improvement (OR: 3.46, 95 % CI: 1.42–8.45) and higher postoperative pregnancy rates (OR: 4.17, 95 % CI: 1.89–9.09). High heterogeneity was noted in some outcomes, reflecting variability in study designs and populations.

Conclusions

Both laparoscopy and hysteroscopy are effective in treating symptomatic isthmocele, with each approach offering distinct advantages. Hysteroscopy is less invasive with faster recovery and better fertility.

Introduction

Cesarean section (C-section) delivery rates have been steadily increasing worldwide [1]. Although cesarean delivery is often perceived as less painful and more convenient than vaginal delivery, it is associated with various complications [2]. Among these, the formation of a cesarean scar defect (CSD), also known as isthmocele or uterine niche, has emerged as a significant concern [3], [4]. Isthmocele is characterized by an abnormal indentation or disruption of the anterior uterine wall at the site of a previous cesarean scar [3], [4]. Several factors are believed to contribute to its development, including the number of prior cesarean sections, cesarean delivery during advanced labor, and lower uterine segment incisions. While these risk factors are documented, the overall understanding of contributing factors remains incomplete [5].

Symptomatic isthmocele can lead to a variety of gynecological issues, including abnormal uterine bleeding (AUB) [6], infertility [7], and chronic pelvic pain [8], significantly affecting women’s reproductive health and quality of life. Surgical interventions are widely employed to manage symptomatic isthmocele by restoring uterine integrity and alleviating associated symptoms [9], [10]. Hysteroscopic repair, a minimally invasive procedure, primarily addresses endometrial abnormalities and is often preferred for smaller defects [11], [12]. Laparoscopic repair, on the other hand, allows for direct visualization and repair of deeper myometrial disruptions and is more suitable for larger or complex isthmoceles [13], [14]. Despite the clinical importance of these techniques, evidence on their comparative efficacy and safety is limited and fragmented.

A review of existing studies highlights the evolving understanding of these surgical approaches. An analysis of isthmocele management has underscored the influence of patient-specific factors, surgical expertise, and resource availability on the choice of treatment modality [15]. Comparative evaluations suggest that hysteroscopic surgery, while less invasive and associated with faster recovery, may not be adequate for patients with significant myometrial defects, where laparoscopic repair is shown to achieve better outcomes [16]. A recent systematic review and meta-analysis further elaborates on these differences, reporting that hysteroscopic repair is effective for patients with sufficient residual myometrium and offers quick symptom relief. Conversely, laparoscopic repair provides superior uterine wall restoration and fertility outcomes for patients with thinner residual myometrium (<2.5 mm) or when hysteroscopic treatment fails. Nonetheless, substantial variability across studies in terms of surgical techniques, outcome measures, and patient selection criteria reveals the lack of standardized protocols in this domain [17].

While surgery effectively improves bleeding symptoms in over 80 % of symptomatic cases, its role in enhancing fertility or reducing obstetric complications in asymptomatic patients remains unclear [17]. Given these gaps in the literature, a systematic evaluation of clinical outcomes and complications of hysteroscopic and laparoscopic approaches is imperative. This systematic review and meta-analysis aim to address this need by providing a comprehensive comparison of these techniques, thereby informing evidence-based clinical decisions for managing symptomatic isthmocele.

Methods

Study design

This study was conducted as a systematic review and meta-analysis to compare the clinical outcomes of laparoscopy and hysteroscopy in the treatment of symptomatic isthmocele. The methodology followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure transparency and reproducibility.

Eligibility criteria

We included studies that investigated the use of laparoscopy or hysteroscopy for treating symptomatic isthmocele, focusing on outcomes such as symptom resolution, postoperative complications and surgical outcomes. Eligible studies were randomized controlled trials, cohort studies, case-control studies, or case series with at least 10 participants in each intervention group. Articles were excluded if they addressed alternative treatment modalities, or lacked sufficient outcome data. Conference abstracts, reviews, case reports and unpublished works were also excluded.

Search strategy

A comprehensive search of PubMed, Embase, Scopus, and Web of Science, up to 11th November 2024 using the following search strategy: ("isthmocele" OR "cesarean scar defect" OR "uterine niche" OR "scar dehiscence") AND ("laparoscopy" OR "laparoscopic surgery" OR "minimally invasive surgery") AND ("hysteroscopy" OR "hysteroscopic surgery"). No restrictions were placed on language or publication year. Reference lists of relevant articles and reviews were manually screened to identify additional eligible studies. Details of the search strategy are provided in Table S1.

Study selection

Two independent reviewers screened the titles and abstracts of all retrieved studies for relevance. Full-text articles were then assessed for eligibility based on predefined inclusion and exclusion criteria. Any disagreements between reviewers were resolved through discussion or consultation with a third reviewer. The selection process was documented using a PRISMA flow diagram. (Fig. 1)

Fig. 1.

PRISMA flow diagram.

Data extraction

A standardized data extraction form was used to collect information from each included study. Extracted data included study characteristics (e.g., author, year, design), patient demographics, and clinical outcomes (symptom resolution, postoperative complications). follow-up duration, and surgical details. Data were independently extracted by two reviewers to ensure accuracy.

Quality assessment

The quality of included studies were assessed using the Newcastle-Ottawa Scale (NOS) [18], focusing on selection, comparability, and outcome domains. Discrepancies in quality assessment were resolved through consensus.

Statistical analysis

The meta-analysis was performed using [software, e.g., Review Manager or Stata]. Continuous outcomes were analyzed using weighted mean differences (WMD) or standardized mean differences (SMD) with 95 % confidence intervals (CIs). Dichotomous outcomes were expressed as odds ratios (ORs) with 95 % CIs. Outcomes of interest in this study are divided into two categories. Primary outcomes (which had at least 5 effect sizes in the meta-analysis) include duration of surgery, and intraoperative blood loss. Secondary outcomes pertain to include overall efficacy, length of stay, infertility, vaginal bleeding and dysmenorrhea. Heterogeneity among studies was assessed using the I² statistic, with values > 50 % indicating substantial heterogeneity. Sensitivity analysis was performed for primary outcomes using the leave-one out method. A random-effects model was employed for heterogeneous data, while a fixed-effects model was used when heterogeneity was low. Publication bias was assessed with funnel plot and egger test if the outcomes had at least 10 effect sizes [19]. All statistical analyses were performed using StataCorp. 2023. Stata Statistical Software: Release 18. College Station, TX: StataCorp LLC.

Results

Study characteristics and quality assessment

A total of 9 studies, published between 2014 and 2024, were included in this systematic review and meta-analysis [20], [21], [22], [23], [24], [25], [26], [27], [28], involving 797 patients who underwent either hysteroscopic or laparoscopic repair for symptomatic isthmocele. All studies were cohort studies, with 7 conducted in China and 2 in Iran. Sample sizes ranged from 41 to 227 patients, with populations including women with symptomatic post-cesarean section uterine diverticula, cesarean scar defects (CSD), or postmenstrual bleeding associated with cesarean section scars. Follow-up durations varied from 6 months to 2 years, with a median of 12 months. Study quality was assessed using NOS, with scores ranging from 7 to 9, indicating overall high methodological quality (Table 1- Table S2).

Table 1.

The characteristics of the included studies.

Author	Year of Publication	Country	Study Type	Population	Sample Size (n)	Hysteroscopy (case)	Laparoscopy (contro;)	Mean/median Duration of follow-up	Quality Score
Fatehnejad, M.	2023	Iran	retrospective cohort study	Patients undergoing laparoscopic or hysteroscopic excision of isthmocele were assessed to enter the study	99	Hysteroscopic interventions were performed for patients with a more than 3-mm thickness in the remaining myometrium at the site of the CS scar.	Patients with a myometrial thickness of less than 3 mm or a failed previous hysteroscopic intervention were selected for laparoscopy.	2 years	8
Hosseini, R.	2024	Iran	prospective cohort	patients who had undergone either laparoscopic or hysteroscopic isthmocele resection	46	The isthmocele was identified and excised using a hysteroscope and cutting current, exposing the muscular layer. The floor was then flattened and electrocoagulated with a roller ball.	The isthmocele was identified with a hysteroscope, excised using a monopolar hook, and the incision site was carefully repaired after removing the upper and lower edges.	12 months	9
Li, C.	2014	china	cohort	Women who had previous cesarean deliveries	41	The cesarean scar contained residual hematometra with chocolate-colored liquid, indicating old menstrual blood. Fibrotic tissue beneath the triangular diverticulum was excised using a resectoscope, and ultrasound confirmed the anterior uterine wall's integrity without isthmus perforation.	The cesarean scar was identified with minimal myometrium and peritoneum covering it. After separating the bladder and suturing the scar, hysteroscopy confirmed the defect's complete correction and normal cervical permeability.	6–19 months	7
Li, W.	2022	china	cohort	patients with CSD	89	Hysteroscopic excision and suture of scar diverticulum.	Laparoscopic excision and suture of scar diverticulum.	NR	7
Lv, B.	2018	China	cohort	patients with symptomatic post-cesarean section uterine diverticulum	82	Operative hysteroscopy was performed with a resectoscope using cutting and coagulation currents to remove anterior scar tissue and align the defect with the cervix. A rollerball cauterized dilated vessels and destroyed the endometrium on the diverticulum's roof.	An electric scalpel was used to incise the peritoneal fold and lower the bladder. The diverticulum was identified and its weakest point located with a probe. Scar tissue was excised laparoscopically with an electric hook, and the defect was repaired with a double-layer closure after trimming to healthy myometrium.	no follow up −21 months	8
Zhang, N. N.	2021	China	Cohort	patients presenting with PCSD-related postmenstrual bleeding	62	Hysteroscopic repair resected the scar's lower rim and coagulated its surface for women with ≥ 3 mm myometrial thickness.	Laparoscopic repair was performed for women desiring future pregnancy with RMT < 3 mm, involving bladder separation, diverticulum excision, and closure with 2–0 absorbable sutures.	3 months	8
Zhang, Q.	2021	China	Cohort	Patients with symptomatic PCSD	46	Hysteroscopic surgery was performed on patients with RM > 3 mm and no fertility preservation needs, using a bipolar resectoscope to remove the defect's inferior edge and electrocauterize the endometrium at the diverticulum's base.	The laparoscopic surgery was mainly performed among patients who had expressed desire for future pregnancy and residual myometrium (RM) less than 3 mmwas used to perform full-thickness suture for wound closure.	1–4 years	7
Zhang, X.	2016	China	cohort	patients with CSDs	105	The procedure was used for defects < 80 % in muscular layer thickness or ≥ 3 mm from the uterine serosa, correcting a dome-like defect into a slope shape using a hysteroscopic resectoscope.	Patients with a CSD diameter > 1 cm or a distance < 5 mm between the uterine serosa and diverticulum underwent excision using hysteroscopic guidance, followed by myometrial suturing with delayed absorbable material and closure of the peritoneum.	laparascopy= 28.6 monthshystrescopy= 21.2 months	8
Zou, Z.	2020	china	cohort	symptomatic post-cesarean section diverticulum	227	Hysteroscopy with continuous perfusion and 5 % mannitol was used to excise scar tissue, trim the lower edge, and promote blood flow. Electrocoagulation was applied to endometrial tissue, ending when no bleeding was observed.	Combined laparoscopy and hysteroscopy excised the diverticulum's muscular wall and sutured the uterine layers, with follow-up hysteroscopy to confirm normal uterine cavity structure.	6 and 12 months	6

Clinical outcomes

A| Primary outcomes:

• 1.Operation Time Hysteroscopic repair demonstrated a non-significant shorter operative time compared to laparoscopic repair (SMD: −2.04, 95 % CI: −4.44–0.36, p = 0.10). Heterogeneity for this outcome was high (I² = 98 %). (Fig. 2-a) Furthermore, sensitivity analysis indicated that the exclusion of the study by Li et al. altered the overall findings, suggesting a relatively low certainty of evidence for the results of this meta-analysis (Fig. S1) [23].
• 2.Intraoperative Blood Loss Hysteroscopic repair was associated with significantly less blood loss than laparoscopic repair (SMD: −2.28, 95 % CI: −3.65 to −0.90, p < 0.05). This outcome showed high heterogeneity (I² =96 %). (Fig. 2-b) Sensitivity analysis confirmed the robustness of our finding (Fig S2).

Fig. 2.

Forest plot for the meta-analysis of a) operation time, b) intraoperative blood loss, and c) length of stay.

B| Secondary outcomes:

• 1.Treatment Efficacy Treatment efficacy, defined as symptom resolution and imaging-confirmed defect repair, was similar between the two groups (OR: 0.80, 95 % CI: 0.21–2.97; p = 0.73). Heterogeneity for this outcome was moderate (I² = 42 %), reflecting consistent results. (Fig. 3-a)
• 2.Infertility Postoperative pregnancy rates were significantly lower among patients undergoing hysteroscopy surgery (OR: 0.24, 95 % CI: 0.11–0.53; p < 0.05). This outcome exhibited low heterogeneity (I² = 4 %), reflecting consistent results. (Fig. 3-c)
• 3.Dysmenorrhea Improvement in dysmenorrhea was observed in patients undergoing laparoscopic repair rather than the hysteroscopic group (OR: 3.46, 95 % CI: 1.42–8.45; p < 0.05; I² = 9 %). However, we should mention that the number of effect sizes for this outcome was relatively low. (Fig. 3-b)
• 4.Length of Stay The hospital stay was significantly shorter for hysteroscopic repair (SMD: −2.62, 95 % CI: −3.52 to −1.72, p < 0.05). Heterogeneity for this outcome was high (I² = 78 %). (Fig. 2-c)
• 5.Postoperative Vaginal Bleeding The duration of postoperative vaginal bleeding was lower in the hysteroscopic group compared to the laparoscopic group. However, the difference was insignificant (SMD: −0.11, 95 % CI: −0.39–0.17, p = 0.43). (Fig. 3-d)

Fig. 3.

Forest plot for the meta-analysis of a) treatment efficacy, b) dysmenorrhea, c) infertility and d) vaginal bleeding.

Discussion

This systematic review and meta-analysis offer a comprehensive evaluation of clinical outcomes and complications associated with hysteroscopic and laparoscopic approaches for managing symptomatic isthmocele, highlighting their respective strengths and limitations. Our study reveals that laparoscopic repair significantly improves fertility outcomes and alleviates dysmenorrhea more effectively than hysteroscopic repair, supported by low heterogeneity in fertility (I² = 4 %) and dysmenorrhea relief (I² = 9 %). Previous research confirms laparoscopic repair’s superiority in patients with RMT < 3 mm due to its enhanced restoration of uterine wall integrity [17]. Robot-assisted laparoscopic repair improves myometrial thickness, achieves high pregnancy rates, and ensures comprehensive symptom resolution, with notable patient satisfaction post-surgery [29]. Evidence supports laparoscopic correction as the preferred method for fertility restoration, as it significantly increases myometrial thickness, whereas hysteroscopic repair may not sufficiently address deeper defects [30]. However, the advanced expertise and equipment required for laparoscopic repair may limit its feasibility in resource-limited settings [31]. Additionally, some patients may be hesitant to undergo general anesthesia, making hysteroscopy an attractive alternative. This approach can often be performed safely and efficiently in an outpatient setting, offering greater accessibility for specific patients [32].

Our findings emphasize hysteroscopic repair as a minimally invasive technique with substantial perioperative advantages, including reduced blood loss, shorter hospital stays, and faster recovery times. These benefits align with its minimal tissue manipulation, making it particularly suitable for smaller defects in patients with RMT > 3 mm [17]. Despite these advantages, high heterogeneity in operative times (I² = 98 %) and blood loss (I² = 96 %) underscores the need for standardized protocols to enhance procedural consistency. Innovative methods, such as the combined use of hysteroscopy, near-infrared vision, and laser fiber for robotic excision, have shown promise in clearly defining isthmocele borders and minimizing tissue damage. Nevertheless, further research is necessary to standardize these advanced techniques and establish a gold-standard surgical approach for cesarean scar defects [33]. Case studies have demonstrated hysteroscopic repair’s effectiveness in resolving complications such as hydrometra and infertility, with successful pregnancies reported post-repair [34], [35]. Furthermore, hysteroscopic isthmoplasty has shown effectiveness in managing abnormal uterine bleeding, although additional research is required to assess its safety for conception and its role in secondary infertility [36]. A randomized controlled trial (RCT) has reported a significant reduction in post-menstrual bleeding in patients undergoing hysteroscopic resection of the isthmocele niche, compared to those receiving expectant management with hormonal therapies [37].

Both surgical approaches demonstrated comparable efficacy in symptom resolution and imaging-confirmed defect repair, indicating their effectiveness when tailored to the patient’s clinical profile. Although postoperative vaginal bleeding was slightly lower in the hysteroscopic group, the difference was not statistically significant, further emphasizing that both techniques effectively address postoperative complications. A systematic review reported improvements in postmenstrual bleeding in 89–93.5 % of cases following vaginal repair and 86 % of cases after laparoscopic correction, with similar pregnancy rates observed between both approaches [38]. Another review found that hysteroscopic treatment of isthmocele-associated secondary infertility in patients with RMT ≥ 2.5 mm is effective, albeit with low complication rates. However, further studies are needed to confirm these findings due to the limited sample sizes and observational nature of the data [39]. A prospective study evaluated treatments for cesarean scar defects (CSDs) from 2010 to 2014. Among 142 participants, treatment options included laparoscopic surgery, vaginal surgery, hysteroscopy, oral contraceptives, and the levonorgestrel intrauterine system. Laparoscopy was the most effective for fertility restoration, with 37.5 % pregnancy success. Hysteroscopy had shorter operation times and hospital stays compared to laparoscopic and vaginal surgeries. All treatments, except the levonorgestrel intrauterine system, reduced menstrual periods. Laparoscopic surgery was particularly beneficial for patients seeking fertility restoration [40].

The findings from this systematic review and meta-analysis carry significant clinical implications for the management of symptomatic isthmocele. For patients with smaller isthmoceles and sufficient residual myometrium, hysteroscopic repair offers a less invasive option, providing benefits such as shorter operative times, reduced blood loss, and faster recovery. However, for patients with larger or more complex defects, laparoscopic repair emerges as the preferred option, especially for those seeking fertility restoration and comprehensive symptom resolution. Clinicians should prioritize individualized treatment plans, considering defect size, depth, reproductive goals, and available surgical expertise. Future research should focus on long-term outcomes and the refinement of minimally invasive approaches for more complex cases, ensuring access to high-quality care worldwide.

This study possesses several notable strengths, including a comprehensive and inclusive search strategy that enhances the validity of our conclusions by incorporating a wide range of relevant studies. Independent evaluations for study selection and quality assessment minimized potential bias, while the use of various meta-analyses facilitated a robust comparison of clinical outcomes and complications. However, several limitations should be considered. Significant heterogeneity in several outcomes, particularly due to variations in patient populations, surgical techniques, and institutional practices, limits the generalizability of the findings. It is important to acknowledge several clinically relevant factors that may influence isthmocele outcomes, such as the number of previous caesarean sections, the type of suture technique used, the presence of postoperative complications (e.g., sepsis or hemorrhage requiring curettage), the need for additional treatment modalities if one fails, the expertise of the surgeon, and the possibility of hysteroscopic repair leading to worsening of the defect [41]. However, the majority of the included studies did not report these variables in sufficient detail. Furthermore, due to the limited number of effect sizes (fewer than 10) in each of our meta-analyses, it was not feasible to perform additional analyses such as subgroup analysis or meta-regression to assess the influence of these factors. Future studies with more comprehensive data reporting and larger sample sizes are needed to better understand the impact of these variables on isthmocele treatment outcomes. Moreover, the geographic concentration of studies in China and Iran raises concerns about the applicability of these results to diverse global populations, as cultural, economic, and healthcare system differences may influence treatment outcomes and limit the generalizability of the findings to broader populations. The cohort design of the studies precludes causal inferences, and randomized controlled trials are needed to confirm the comparative efficacy and safety of the two surgical approaches. Furthermore, the small sample sizes in some studies and retrospective designs may introduce biases, which should be addressed in future research. Clinically, the choice between hysteroscopic and laparoscopic repair should be guided by factors such as defect severity, reproductive goals, and available surgical expertise, with hysteroscopy preferred for less complex cases and laparoscopic repair for more extensive defects requiring comprehensive correction. Future research should prioritize prospective, multicenter studies with standardized patient selection, surgical technique, and outcome assessment criteria, and investigate long-term obstetric outcomes and innovative surgical approaches, such as robotic-assisted laparoscopy. Expanding access to advanced surgical modalities in resource-limited settings is also crucial to ensure equitable care for patients with symptomatic isthmocele.

In conclusion, this systematic review and meta-analysis provides a comprehensive evaluation of hysteroscopic and laparoscopic approaches for managing symptomatic isthmocele, emphasizing the importance of individualized surgical planning. Both techniques are effective in improving clinical outcomes, but their selection should be based on patient-specific factors, such as defect size, residual myometrial thickness, and reproductive goals. While laparoscopic repair offers superior outcomes for extensive defects, hysteroscopy remains a viable option for smaller isthmoceles, offering significant perioperative advantages. The findings underscore the need for standardized protocols, further research, and expanded access to advanced surgical modalities to ensure optimal care for diverse patient populations.

Funding

This study did not receive funding, grant, or sponsorship from any individuals or organizations.

Ethical statement

Not applicable, this systematic review and meta-analysis was registered in PROSPERO with the registration number CRD420251028603.

CRediT authorship contribution statement

Zahra Ramezani: Writing – review & editing, Writing – original draft, Validation, Data curation. Saba Goodarzi: Writing – review & editing, Writing – original draft, Visualization, Project administration, Data curation. Pegah Rashidian: Writing – original draft, Validation, Formal analysis, Conceptualization. Hadis Rastad: Writing – review & editing, Visualization, Validation, Methodology. Mona Esmi: Writing – review & editing, Visualization, Validation, Methodology, Conceptualization. Mahmood Bakhtiyari: Writing – original draft, Validation, Resources, Methodology, Formal analysis. Shima Mohammadian: Writing – review & editing, Visualization, Validation, Methodology. shafiee Arman: Writing – review & editing, Writing – original draft, Visualization, Supervision, Project administration, Formal analysis.

Consent for publication

Not applicable.

Declaration of Competing Interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript.

Appendix A. Supplementary material

Supplementary material

Data availability

All data has been presented in the manuscript.